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When applying for certain public benefits, individuals are required to complete the Applicant Status Affidavit form, a crucial document designed to establish eligibility and identity. This affidavit demands specific personal information, including the applicant's full name, Social Security Number, and details regarding citizenship status. Options on the form make it clear whether the applicant is a U.S. citizen, a legal permanent resident, or a qualified alien, which is critical for compliance with federal and state regulations. Furthermore, non-citizens must present an unexpired Employment Authorization Document, along with their Alien Registration Number or other identifying information, to ensure their legal standing in the United States. Given the sensitive nature of this information, the affidavit includes a Consent to Disclosure section, wherein applicants can choose to waive certain confidentiality protections. This waiver permits the Department of Homeland Security to communicate with the Georgia Department of Labor, facilitating the accurate assessment of eligibility for unemployment benefits. The form stresses the importance of honesty, detailing the consequences of submitting false statements, which can lead to legal repercussions. Collectively, these features aim to ensure that public benefits are allocated to those who genuinely qualify, thereby maintaining the integrity of the system.

Applicant Status Affidavit Example

STATE OF

 

BYB/Add. CWB Date

COUNTY OF

 

 

 

 

 

 

 

APPLICANT STATUS AFFIDAVIT

 

 

 

 

 

 

[O.C.G.A. 50-36-1]

Comes now the undersigned, who, upon oath duly taken, states:

1. My full name is

 

 

 

 

and my Social Security Number is

 

-

 

 

-

 

. I provide my unexpired government-issued picture identification

in support of this declaration of my name and identity. I am an applicant for a public benefit, and I am making the rep- resentations in this AFFIDAVIT to obtain that public benefit.

2.

I was born in [NAME OF COUNTRY]

on

/

/

 

, and I am 18 years

of age or older.

 

 

 

 

 

 

 

 

 

 

 

 

3.

I declare [INITIAL ONE]: [

 

] that I am a U.S. Citizen; OR [

 

 

 

] that I am a legal permanent resident;

OR [ ] that I am a qualified alien or non-immigrant under the federal Immigration and Nationality Act, Title 8 U.S.C.,

as amended, lawfully present in the United States.

4.Unexpired Employment Authorization Document: REQUIRED OF ALL NON-CITIZENS. If I indicated other than United States citizenship in item #3 above, my Alien Registration Number issued by the Department of Homeland Security or other federal immigration agency or other number is:

Alien Registration #

 

Card #

 

 

 

Citizenship Cert #

 

 

Passport #

 

(with)

Naturalization #

 

 

I-94

Stamp #

 

 

(or)

SEVIS ID #

 

 

I-551 Stamp #

 

 

 

Expiration Date:

 

 

I-94

#

 

 

 

 

 

 

 

5.Consent to Disclosure. I freely and voluntarily waive the confidentiality provisions of the Immigration

Reform and Control Act of 1986 (IRCA) to permit the Department of Homeland Security (DHS) to provide the Georgia Department of Labor information regarding my alien status for purposes of determining my eligibility for unemployment insurance benefits. I understand that IRCA precludes DHS from using, publishing, or making available information related to my application for adjustment to temporary residence except as provided by law (confidentiality provision).

6.I understand that knowingly and willingly making a false, fictitious, or fraudulent statement or representation in this affidavit is a violation of O.C.G.A. Code Section 16-10-20 and is subject to criminal prosecution under that and other state and federal laws. I swear or affirm that the citizenship and other information I have provided here is true and correct to the best of my personal knowledge and belief.

Applicant Signature:

Claims Taker Signature

Employee ID# (4 digits):

For Central Office Only:

Cert #

 

 

Emp. Elig. Date

 

 

Secondary Verification

q Yes q No

Remarks

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DOL-1054A (R-3/20) Page 1of 2

Name:

 

SSN:

SECURE AND VERIFIABLE DOCUMENTS UNDER O.C.G.A. & 50-36-2

Initials:

An unexpired United States passport or passport card

An unexpired United States military identification card

An unexpired driver’s license issued by one of the United States, the District of Columbia, the Commonwealth of Puerto Rico, Guam, the Commonwealth of the Northern Marianas Islands, the United States Virgin Islands, American Samoa, or the Swain Islands, provided that it contains a photograph of the bearer or lists sufficient identifying information regarding the bearer, such as name, date of birth, gender, height, eye color, and address to enable the identification of the bearer

An unexpired identification card issued by one of the United States, the District of Columbia, the commonwealth of Puerto Rico, Guam, the Commonwealth of the Northern Marianas Islands, the United States Virgin Islands, American Samoa, or the Swain Islands, provided that it contains a photograph of the bearer or lists sufficient identifying information regarding the bearer, such as name, date of birth, gender, height, eye color, and address to enable the identification of the bearer

An unexpired tribal identification card of a federally recognized Native American tribe, provided that it contains a photograph of the bearer or lists sufficient identifying information regarding the bearer, such as name, date of birth, gender, height, eye color, and address to enable the identification of the bearer

An unexpired United States Permanent Resident Card or Alien Registration Receipt Card

An unexpired Employment Authorization Document that contains a photograph of the bearer

An unexpired passport issued by a foreign government accompanied by a federal form specifying an individual’s lawful immigration status or other proof of lawful presence under federal immigration law

An unexpired Merchant Mariner Document or Merchant Mariner Credential issued by the United States Coast Guard

An unexpired Free and Secure Trade (FAST) card

An unexpired NEXUS card

An unexpired Secure Electronic Network for Travelers Rapid Inspection (SENTRI) card

An unexpired driver’s license issued by a Canadian government authority

A Certificate of Citizenship issued by the United States Department of Citizenship and Immigration Services (USCIS)

A Certificate of Naturalization issued by the United States Department of Citizenship and Immigration Services (USCIS) (Form N-550 or Form N-570)

Certification of Birth issued by the United States Department of State (Form DS-1350) with an unexpired government-issued picture identification

Certification of Birth Abroad issued by the United States Department of State (Form FS-545) with an unexpired government-issued picture identification

Consular Report of Birth issued by the United States Department of State (Form FS-240) with an unexpired government-issued picture identification

An original or certified copy of a birth certificate issued by a state, county, municipal authority, or territory of the United States bearing an official seal with an unexpired government-issued picture identification

DOL-1054A (R-3/20) Page 2 of 2

Form Characteristics

Fact Name Description
Governing Law This affidavit is governed by the Official Code of Georgia Annotated (O.C.G.A.) § 50-36-1.
Purpose The form is used to declare an applicant's identity and eligibility for public benefits.
Eligibility Verification Applicants must provide unexpired government-issued photo identification to support their claims.
Citizen Status Declaration Applicants must indicate their citizenship status by checking one of three options provided.
Disclosure Consent By signing, applicants waive confidentiality of their immigration status to facilitate benefit eligibility checks.
False Statements Falsifying information may lead to criminal prosecution under O.C.G.A. § 16-10-20.
Secure Documents The affidavit lists various forms of secure and verifiable documents that applicants may use to prove identity and status.

Guidelines on Utilizing Applicant Status Affidavit

Once you have gathered all necessary documentation, it's time to fill out the Applicant Status Affidavit form. This process is crucial as it verifies your identity and citizenship status as part of your application for public benefits. Ensure that all information is accurate and complete before submitting the form.

  1. Start with the name section. Write your full name in the designated space.
  2. Provide your Social Security Number in the appropriate section.
  3. Attach a copy of your unexpired government-issued picture identification to support the declaration of your name and identity.
  4. In the birthplace section, indicate where you were born by filling in the name of the country and your date of birth.
  5. Confirm your age by checking the box that denotes you are 18 years of age or older.
  6. In the citizenship declaration, initial one box to indicate your status: U.S. Citizen, legal permanent resident, or qualified alien/non-immigrant.
  7. If you are not a U.S. citizen, provide your Alien Registration Number or another identifying number in the corresponding field.
  8. Indicate the expiration date of your employment authorization document or other immigration documents, as applicable.
  9. Agree to the consent to disclosure clause by checking the appropriate box, acknowledging that you waive confidentiality provisions.
  10. Read and understand the implications of making a false statement, then proceed to the applicant signature line to sign your name.
  11. If required, a claims taker will also sign and enter their employee ID number in the designated area.

After completing the form, ensure all sections are filled out clearly. Review the entire affidavit for accuracy to prevent any delays in processing. Once confirmed, submit your completed form along with any required documents to the relevant authority for further processing.

What You Should Know About This Form

What is the purpose of the Applicant Status Affidavit form?

The Applicant Status Affidavit is a document required to confirm an individual's eligibility for public benefits, specifically in the context of employment and unemployment services in Georgia. By completing this affidavit, applicants declare their citizenship or immigration status, providing essential information to determine their eligibility for benefits.

Who needs to complete the Applicant Status Affidavit?

Anyone applying for a public benefit in Georgia needs to complete the Applicant Status Affidavit. This includes citizens, legal permanent residents, and qualified aliens or non-immigrants. It ensures that the Georgia Department of Labor has the necessary information to assess each applicant's eligibility accurately.

What information is required on the form?

The form requires personal information, such as your full name, Social Security Number, and country of birth. You'll also need to indicate your citizenship or immigration status by checking the appropriate box. If you're a non-citizen, you are required to provide an Alien Registration Number or other relevant identification numbers and the expiration date of any documents issued to you by the Department of Homeland Security.

What if I am not a U.S. citizen?

If you are not a U.S. citizen, you need to specify your immigration status in the affidavit. You may declare that you are a legal permanent resident or a qualified alien/non-immigrant. Additionally, you will need to provide documentation, such as an Employment Authorization Document or an Alien Registration number, to support your claim.

Are there penalties for providing false information on the affidavit?

Yes, there are significant penalties for submitting false information on the affidavit. Knowingly providing false statements can lead to criminal prosecution under both state and federal laws. It is crucial that the information you provide is truthful and accurate to avoid any legal repercussions.

Is consent for disclosure mandatory?

While consent for disclosure is an important part of the affidavit process, it is not mandatory. However, by waiving confidentiality provisions, you allow the Department of Homeland Security to provide information about your status to the Georgia Department of Labor. This can facilitate your access to public benefit programs.

What forms of identification can I provide?

You must present an unexpired government-issued picture identification to support your identity on the form. Acceptable documents can include U.S. passports, state-issued driver's licenses, military IDs, and various other forms of official identification. Each form must contain sufficient identifying information like your name and date of birth.

How long is the affidavit valid?

The affidavit itself does not expire; it is valid for the duration of your eligibility for the public benefit for which you are applying. However, if your identification documents or your immigration status change, you should update the affidavit to reflect this new information.

Where do I submit the completed affidavit?

The completed Applicant Status Affidavit form should be submitted to the appropriate claims taker or department in the Georgia Department of Labor. Be sure to keep a copy for your records, as it serves as proof of your application and the information you provided.

Common mistakes

Filling out the Applicant Status Affidavit form can seem straightforward, but many make mistakes that can delay their applications. One common mistake is leaving out essential personal information. In section one, you must include your full name and Social Security Number. Missing this information can lead to automatic disqualification. Always double-check these details before submitting.

Another frequent error involves not providing valid identification. The form requires an unexpired government-issued picture ID to verify your identity. Some applicants think a document is acceptable, only to realize later that it has expired. It’s crucial to take the time to gather the correct documentation before completion.

Many also struggle with the citizenship declaration in section three. Some people tick a box without understanding what it means. Make sure you clearly understand whether you’re a U.S. citizen, a legal permanent resident, or a qualified alien. Misrepresentation can have serious legal consequences, so it's essential to be honest and precise.

Next, consider the requirement for an Employment Authorization Document if you are not a U.S. citizen. This documentation is often overlooked, especially by first-time applicants. If you mark one of the non-citizen options in section three, ensure that you include a valid Alien Registration Number or other necessary identification numbers. Leaving this blank could result in delays or denials.

Finally, many applicants forget to review the consent to disclosure in section five. It's easy to skip this part, but you need to understand the implications of waiving confidentiality. By agreeing, you are allowing the Department of Homeland Security to share your status with the Georgia Department of Labor. Being unaware of what you’re consenting to can lead to misunderstandings later on.

Documents used along the form

When applying for a public benefit, it's essential to have the correct documentation in order. Along with the Applicant Status Affidavit form, there are several other documents that might be necessary. Here's a brief overview of each.

  • Unexpired Government-Issued ID: A valid form of identification, such as a driver's license or passport, used to verify your identity and citizenship status.
  • Employment Authorization Document: Required for non-citizens to prove legal employment status in the U.S.
  • Permanent Resident Card: Also known as a green card, this proves your status as a lawful permanent resident of the U.S.
  • Certificate of Citizenship: This document confirms your status as a U.S. citizen, issued by USCIS.
  • Certificate of Naturalization: This shows proof of your naturalization as a U.S. citizen, usually following an immigration process.
  • Birth Certificate: An official document that records your birth, often required to establish identity and age.
  • Foreign Passport with Proof of Status: A valid passport from another country, accompanied by documentation that proves your lawful presence in the U.S.
  • Tribal Identification Card: An ID issued by a federally recognized Native American tribe, used to verify identity and tribal affiliation.

Having these documents ready can make the application process smoother. It is crucial to ensure all information is accurate, as any discrepancies can lead to delays or complications.

Similar forms

The Applicant Status Affidavit form has similarities with several other documents that serve to verify identity and legal status. Below are four such documents, each compared with the Applicant Status Affidavit:

  • Employment Authorization Document (EAD): Like the Applicant Status Affidavit, the EAD verifies the residency and work authorization of non-citizens in the U.S. Individuals applying for benefits must provide proof of lawful presence, similar to the conditions set forth in the affidavit.
  • Certificate of Naturalization: This document proves that an individual has become a U.S. citizen. As with the Applicant Status Affidavit, this certificate confirms the person’s identity and legal status in the country, allowing them to access benefits intended for citizens.
  • U.S. Passport: A U.S. passport verifies both identity and citizenship. Much like the Applicant Status Affidavit, it provides crucial personal information that proves eligibility for public benefits while being a secure and widely accepted form of identification.
  • Permanent Resident Card (Green Card): This card identifies an individual as a lawful permanent resident of the U.S. Similar to the affidavit, it confirms residency status, ensuring that the holder can access certain benefits without restrictions faced by non-residents.

Dos and Don'ts

When filling out the Applicant Status Affidavit form, it's essential to carefully navigate the process to ensure accuracy and compliance. Here are some important dos and don’ts:

  • Do provide your full name and Social Security Number clearly.
  • Do ensure your government-issued identification is unexpired and includes a photograph.
  • Do select only one option regarding your citizenship status in Section 3.
  • Do include any required documentation, especially if you are a non-citizen.
  • Don’t leave any sections blank; complete all required fields.
  • Don’t submit false information, as this can lead to legal consequences.

Keep these tips in mind to help streamline your application process and avoid common pitfalls. Accuracy is key!

Misconceptions

Misconceptions regarding the Applicant Status Affidavit form can lead to confusion and possible legal issues. Here are five common misconceptions:

  • All applicants must submit the same documents. Applicants often believe that everyone must provide identical identification. However, the required documents vary depending on an individual's immigration status and the specific benefits being applied for.
  • Only U.S. citizens can complete this form. Some individuals think that this affidavit is exclusive to U.S. citizens. In reality, legal permanent residents and qualified aliens can also submit this form to access certain public benefits.
  • The affidavit does not require a signature. A common misunderstanding is that a signature is optional. However, the affidavit must be signed to affirm that the information provided is truthful and accurate.
  • Confidentiality is guaranteed. Many applicants mistakenly believe that their information will remain completely confidential. While the form includes a consent to disclose certain information, applicants should be aware that some details may be shared with authorized entities as required by law.
  • Providing false information is not a serious issue. Some individuals may think that inaccuracies in the affidavit are insignificant. In fact, knowingly providing false information can lead to criminal prosecution and disqualification from public benefits.

Key takeaways

Here are crucial points to keep in mind when filling out and using the Applicant Status Affidavit form:

  • Ensure you provide your full name and Social Security Number accurately. This information verifies your identity and is essential for the application.
  • Use an unexpired government-issued picture ID. This document must accompany your affidavit to support your identity declaration.
  • Clearly indicate your citizenship status. You must select one option: U.S. Citizen, legal permanent resident, or qualified alien/non-immigrant.
  • If applicable, provide your Alien Registration Number. This is a mandated section for non-citizens to establish legal presence in the U.S.
  • Be aware of the confidentiality waiver. By filling out this form, you allow the Department of Homeland Security to share your immigration status information for unemployment benefit eligibility.
  • Double-check all declarations. Making a false statement is a serious offense that can lead to criminal prosecution. It is vital to ensure that all information is accurate and truthful.